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AHIMA Certified Documentation Integrity Practitioner Sample Questions:

1. A patient presents to the emergency room with complaint of cough with thick yellow/greenish sputum, and generalized pain. Admitting vital signs are noted below and sputum culture performed. The patient is admitted with septicemia due to pneumonia and has received 2L of normal saline and piperacillin/ tazobactam. After all results were reviewed, on day 2, the hospitalist continued to document septicemia due to pneumonia.
White blood count BC 18,000
Temperature 101.5
Heart rate 110
Respiratory rate 24
Blood pressure 95/67
Sputum culture (+) klebsiella pneumoniae
Which diagnosis implies that a query was sent and answered?

A) Sepsis with respiratory failure due to pneumonia
B) Sepsis with pneumonia due to klebsiella pneumoniae
C) Septicemia due to klebsiella pneumoniae
D) Severe sepsis with pneumonia due to klebsiella pneumoniae

2. A patient receives a blood transfusion after a 400 ml blood loss during surgery. The clinical documentation integrity practitioner (CDIP) queries the physician for an associated diagnosis. The facility does not maintain queries as part of the permanent health record. What does the physician need to document for the CDIP to record the query as answered and agreed?

A) A cause-and-effect relationship between anemia and the underlying cause
B) The associated diagnosis directly on the query form
C) That the blood loss was not clinically significant
D) The associated diagnosis and the clinical rationale in the progress notes

3. Tracking denials within the clinical documentation integrity program is important to

A) determine coding inaccuracies and educate as necessary
B) identify documentation improvement opportunities and educate as necessary
C) confirm reimbursement was appropriate
D) file a timely appeal if the medical center disagrees with the RAC findings

4. An otherwise healthy male was admitted to undergo a total hip replacement as treatment for ongoing primary osteoarthritis of the right hip. During the post-operative period, the patient choked on liquids which resulted in aspiration pneumonia as shown on chest x-ray.
Intravenous antibiotics were administered, and the pneumonia was
monitored for improvement with two additional chest x-rays. The patient was discharged to home in stable condition on post-operative day 5.
Final Diagnoses:
1. Primary osteoarthritis of right hip status post uncomplicated total hip replacement
2. Aspiration pneumonia due to choking on liquid episode
What is the correct diagnostic related group assignment?

A) 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC
B) 469 Major Joint Replacement or Reattachment of Lower Extremity with MCC
C) 179 Respiratory Infections and Inflammations without CC/MCC
D) 553 Bone Diseases and Arthropathies with MCC

5. An 88-year-old male is admitted with a fever, cough, and leukocytosis. The physician documents admit for probable sepsis due to urinary tract infection (UTI). Antibiotics are started. Three days later, the blood and urine cultures are negative, the patient has been afebrile since admission, and the white blood count is returning to normal. What documentation clarification is needed to support accurate coding of the record?

A) Send a clinical validation query for only the diagnosis of sepsis.
B) A clinical validation query is not required for either diagnosis.
C) Send a clinical validation query for both the diagnoses of sepsis and UTI.
D) Send a clinical validation query for only the diagnosis of UTI.

Solutions: